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22 April 2015

Q&A: Why does unplanned pregnancy happen?

There remains a gap between policymakers' understanding of the causes and 'solutions' to unplanned pregnancy, and the reality of people's lives.

In the run-up to the 2015 BPAS/Royal Society of Medicine conference, ‘Decriminalisation and demedicalisation: Rethinking family planning for the 21st century’ (London, 10 June), we look at some of the factors that shape women’s contraceptive use and pregnancy choices today.

1) How do policymakers view family planning?

‘Family planning’ has been an accepted part of public health policy for 50 years. In 1967, the National Health Service Amendment (Family Planning) Act gave permission for Local Authority contraceptive provision to be expanded from medical grounds to social criteria and placed no restrictions on age or marital status.

The 1972 National Health Services Reorganisation Bill included a clause that led to provision of free contraceptive advice and services by the NHS, from 1974 onwards. And the 1967 Abortion Act made it legal to terminate her pregnancy, provided that two doctors agreed this was in the best interests of her mental or physical health.

In order for women to plan their families with any degree of certainty, they need access both to effective methods of contraception, and to abortion. Contraception alone has never been enough to allow women to control their fertility, and this remains the case today. An analysis by BPAS in 2014 found that two thirds (66%) of women receiving care at its clinics reported using a form of contraception when they conceived. This finding comes as no surprise: as discussed below, contraceptive failure has always been an important factor in why women need to seek abortion.

The focus of ‘family planning’ has always been on encouraging contraceptive use, both as a means of avoiding unwanted pregnancies and avoiding abortion. This focus on planning pregnancy with contraception is underlined by the Department of Health’s 2013 policy, A Framework for Sexual Health Improvement in England.

In the Foreword Anna Soubry MP, then Parliamentary Under Secretary of State for Public Health, emphasised that ‘good sexual health’, as well as being important to individuals, ‘is a key public health issue as well’. She stressed that policymakers should work to bring about ‘a fall in the number of unwanted pregnancies, especially those that result in terminations’.

Official approaches to family planning tend to be based on a number of assumptions. First, that unplanned, or unwanted, pregnancy is largely avoidable through the use of contraception. Second, that pregnancy falls into such neat categories as ‘unplanned’ or ‘unwanted’, and indeed that these two adjectives mean the same thing.

Third, that policy can and should have a role, not only in supporting women’s ability to control their fertility through access to contraceptive and abortion services, but in shaping their pregnancy intentions, to the extent that ‘a fall in the number of unwanted pregnancies’ can be considered an achievable policy goal.

Yet these assumptions do not always fit with the reality of people’s lives.

2) How is unplanned pregnancy defined?

It is impossible to calculate precisely just how many pregnancies each year are accidental, or completely unplanned. When medical sociologist Anne Fleissig, in the 1980s, asked a number of women who had given birth six weeks previously about whether their pregnancy was planned, she found that 31 per cent of them were not. She concluded in a paper subsequently published in the British Medical Journal that almost a third of births could be the consequence of accidental pregnancies. If this were the case it would mean 310, 000 accidental pregnancies in Britain every year.

This was likely to be a conservative estimate: because Anne Fleissig conducted her research into the circumstances in which women’s new babies were conceived, her sample did not include women who had conceived but ended the pregnancy by an abortion. When these unplanned pregnancies are considered as well, it suggests the real extent of accidental pregnancy is even higher. For example, in 2013 there were 185,331 abortions in England and Wales, and many (though not all) of these will be to women whose pregnancies were unintended.

However, it is extremely difficult to draw a clear line between those pregnancies that are planned and those that are unplanned. The third National Survey of Sexual Attitudes and Lifestyles (Natsal), published in 2013, analysed data from women of childbearing age between 2010 and 2012. Natsal found that only 16.2% of pregnancies experienced in the past year were completely unplanned, and just over half were planned. The remainder (29%) were defined as ‘ambivalent’.

An interesting paper by Sarah Earle in 2004 draws on interview data to develop four categories of pregnancy intention. Earle writes:

‘The first category [the planned pregnancy] is unambiguous and reflects the type of planned approach currently advocated by health professionals. The second category [the laissez-faire pregnancy] reflects the experiences of women who stop using contraception but adopt a more relaxed approach to pregnancy planning. The third category [the recalcitrant pregnancy] is far more ambiguous and describes the experiences of those who want to be pregnant but for whom it would not be socially acceptable to plan a pregnancy. The final category [the accidental pregnancy] is unambiguous and deals with pregnancies that could be described as unexpected, and arising due to genuine contraceptive failure.’

Whether a woman continues her pregnancy to term or whether she ends it in abortion, her intentions about her pregnancy and her feelings about the pregnancy will often be far more subtle and ambiguous than policymakers often allow.

3) Why are pregnancies not always planned?

It is difficult to arrange a pregnancy to order. The average fertile couple trying for a child may take three or four months to conceive, and many couples go through a stage where they are not exactly planning to have a child now, but at the same time they are not exactly doing everything in their power to prevent it either.

Women who use the contraceptive pill sometimes switch to a barrier method of contraception, such as a condom, a few months before they intend to start ‘trying’ for a child. Barrier methods are inherently less effective and if the couple has difficulty using them, and happens to be highly fertile it is quite possible that the pregnancy intended for three months hence arrives sooner than planned.

Other similar situations may arise. For example what about the situation where one partner wants a child, but the other is reluctant? A woman may assert her maternal ambitions by frequently ‘forgetting’ to take her contraceptive pill thereby becoming pregnant ‘accidentally on purpose’. She may always insist that she conceived unintentionally, never admitting that she took chances that she would not have taken had she been committed to avoiding pregnancy. Or a man may ‘forget’ to buy condoms, insist if they have sex he will withdraw before ejaculation and then get ‘carried away’. Sometimes these manoeuvres are quite conscious and deliberate; at other times they are not.

An ‘accidentally on purpose’ pregnancy may even be the consequence of a woman’s insecurity about her own fertility. The frequent discussions about infertility in newspapers, women’s magazines and on television may lead some women to doubt their own ability to have a child when the time is right.

If a woman who has never had a child frequently reads about the sub-fertility problems of others, and takes to heart the statistic that one couple in six experiences fertility problems, she may well suffer all manner of doubts and fears about her reproductive future. She may not want a child now but subconsciously might want to discover if she can. It is also possible for accidental pregnancies to be disguised as deliberate conceptions. A woman may be embarrassed to admit that a pregnancy is accidental in case she is thought to be stupid, or it confers some kind of stigma on her future child. Many other women feel genuinely ambivalent about their pregnancy and are quite honestly unsure whether it was intended or ‘just happened’.

The ambiguous nature of pregnancy intentions is one possible reason why long-acting reversible methods of contraception (LARCs), such as the coil or the implant, are not demanded by all sexually-active women who wish to avoid pregnancy. LARC methods are far more effective than the more popular methods such as the condom and the pill, and once inserted by a medical professional, will give protection against unintended pregnancy for three to five years.

Yet while this effectiveness is a bonus for women who are absolutely sure that they do not want a child, or another child, for at least five years, it might be a drawback for women who know they don’t want a baby right now, but do not want to make a decision that seems to reach so far into the future, and so completely removes the role of chance.

4) What wider changes affect pregnancy planning?

In many cases, however, there is no doubt at all about the accidental character of a pregnancy. Women become pregnant in circumstances where they have absolutely no desire to conceive and have done absolutely everything possible to prevent conception.

Despite modern contraception, better provision of sex education, and greater scientific knowledge about human reproduction, a number of factors combine to place women today at just as great a risk of unplanned pregnancy as previous generations. We probably have sex more often, we may have a greater number of partners during our lives and our expectations of sex are different.

Whereas for earlier generations sex was linked more to marriage and motherhood, it is now regarded by most of society as a legitimate form of recreational activity. This point was underlined by Kaye Wellings and Anne Johnson, lead authors of the 2013 Natsal study. Noting that today, ‘sexual activity is not primarily, or even necessarily, about reproduction’, they write:

‘In a growing number of contexts globally, the separation of sexual activity from reproduction is well under way as contraception, abortion, and assisted reproduction have weakened the natural link.’

This has an important impact on sexual behaviour. Unlike previous generations, who constantly feared pregnancy, women today expect to enjoy sex without consequences. And the more times a woman has sex, the greater her chances of falling pregnant. This simple fact means that we may risk accidental pregnancies more than previous generations simply because our active sex life extends over a longer period of time than that of our parents and grandparents.

It is no longer expected that women in their twenties should be either married and preparing to embark on family life, or on the look-out for a husband. Today’s twenty-somethings are likely to be continuing their education, forging careers, or simply enjoying a break between leaving their parents’ family life and starting their own. Even if a couple settles into a stable heterosexual relationship and achieves a secure income and a decent home, it is still considered normal and appropriate for them to defer children until their late twenties or early thirties. And all the time that they are deferring a deliberate pregnancy they have the chance of an accidental one.

Society still assumes that ‘normal’ women will want children at some time in their lives, but an increasing number of couples are deciding that their priorities lie elsewhere and parenthood is not for them. Recent statistics suggest that around 1 in 5 women at the end of the childbearing years (born in 1967) are childless, compared with their mother’s generation (born in 1940), where 1 in 9 were childless. While some of these women will have experienced fertility problem, much of the increase is accounted for by women who are ‘childless by choice’.

Accidental pregnancy can also be a big problem for women who already have planned and wanted children. Another addition to the family may bring about emotional and financial pressures that are damaging to the couple and their existing children. A woman struggling to cope with young children may find that organising her own contraception is the one job that drops from her busy agenda.

Women might experience an accidental pregnancy shortly after the birth of a new baby, when they may be preoccupied with mothering and not yet settled into a new contraceptive regime. Fertility can return within a few months of childbirth, particularly if the new mother is not breastfeeding.

While a woman’s fertility level starts to decline from her mid-thirties, women can and do get pregnant right up until their menopause. An older woman with an unexpected pregnancy might mistake the absence of her periods for the start of menopausal symptoms and not identify the problem for months. The woman may be distressed by the knowledge that the child will have a far greater statistical risk of disability. The couple may worry that they are just ‘too old’ to cope with the stresses and strains of baby-care. Yet as long as they are having sex, they have a chance of becoming pregnant – which may be increased if they have relied on the pill for contraception and the woman has now been advised to change, because of her age, to a new and unfamiliar method.

In 2013, 8372 women aged 40 and over had abortions, including 686 women above the age of 45, and 24 women aged 50 and over. But at the same time, the number of births to women over 40 has been increasing, following the trend towards later motherhood; and the percentage of conceptions leading to abortion has generally decreased for women aged 40 and over. Again, policy-makers often miss the extent to which women in their early forties are not only fertile – they might actively want to be pregnant. Contraception, abortion, and maternity services all need to work with this reality.

For all fertile women who are sexually active, accidental, unintended, or unplanned pregnancy is a risk. We live in an age when it is accepted that pregnancies are no longer events that just happen either by the ‘grace of God’ or by ‘acts of nature’. Our lives are organised to incorporate sex for enjoyment and emotional satisfaction and it is seen as quite normal that we should wish to suppress our fertility.

Yet at the same time, the messy reality of life, relationships and decision-making means that women cannot, or do not always want to, plan a pregnancy with precision. It may women take longer than expected to meet the partner with whom they want to have a baby; it may take less time than anticipated to conceive with that partner; the relationship may break down, changing how the woman feels about her pregnancy.

When a split condom, a missed pill, or a moment of carefree intimacy leads to an unplanned pregnancy, this can be experienced in a whole number of ways – from a personal disaster to a serendipitous opportunity. A narrow policy response that equates unplanned with unwanted – or conversely, planned with wanted – simply misses the complexity of women’s emptions and experiences.

5) Why don’t people use contraception perfectly?

In the final analysis contraception is something we all use reluctantly. We do not take the pill, use a condom, or have an IUD fitted because we want to engage in that activity in its own right but as a precaution: to allow us to enjoy sex without pregnancy. We weigh up the pros and cons – the hassle of using a contraceptive appropriately is balanced against the fear of becoming pregnant. Any disincentives to use a method, whether it be the problem of obtaining it or unhappiness with the way a method makes us feel all help tip the balance against effective contraceptive usage.

This was the point elaborated in the US sociology professor Kristin Luker’s seminal book Taking Chances: Abortion and the decision not to contracept, published in 1975. Speaking at the BPAS annual lecture in 2010, Luker referred back to this research, looking at what has changed today. One thing that has remained constant in 35 years is that, despite developments in contraceptive technology, information, and provision, individuals and couples still perceive a range of costs to contraceptive use.

Luker’s research was with a group of people who had successfully shown that they knew how to use contraception in the past, yet had not used it to prevent the pregnancy they were currently experiencing. ‘When I talked to them, it turned out that it was because contraception brings social, physical and emotional costs,’ she explained:

‘The social cost is, you have to acknowledge that you’re going to be sexually active. A surprising number of people in my very first study, and a surprising number of young people I talk to today, go off the pill when they break up with a boyfriend, because they’re not “looking to have sex” and they don’t want to look like a woman who’s “looking to have sex”. So it was a common pattern many years ago and it’s still common.’

Trying to calculate the odds of getting pregnant, explained Luker, is ‘a statistician’s nightmare, and it’s not surprising that individual people have a hard time with it’. A common statistic used is that healthy women in a regular sexual relationship have an 80 per cent chance of pregnancy over the course of a year. As Luker says:

‘But it only takes a moment’s reflection to realise that you don’t get 80 per cent pregnant – it’s zero or one. So calculating your aggregate risk is very difficult, and many people will just sort of use a condom during what they thought was the unsafe time of the month, or they’d use a diaphragm or maybe some foam, and when nothing happened they’d stop using it a little bit more, and more, and more. And finally the last step in this process is that people said to themselves, worst coming to worst, I can always get an abortion.’

The way that individuals and couples actually experience contraceptive use is therefore far more complex than policymakers tend to assume. In this context, it should be clear that women who have accidental pregnancies are not stupid, they are not necessarily careless, and are certainly not feckless or irresponsible. The only way to remain 100 per cent sure of never experiencing an unplanned or unwanted pregnancy is to restrict sex to those times when you want to conceive: a choice of lifestyle that most of us would find unacceptable.

Conversely, in a social context where we expect to be able to have sex without becoming pregnant, and we have access to legal abortion if we do, the fact that people ‘take chances’ with contraception should be viewed as neither a surprise, nor a problem.

6) How might we think about family planning in the 21st century?

Kristin Luker has concluded that, after four decades of research, ‘there are three levels of forces impinging on people: at the level of the individual, at the level of the couple, and at the level of society.’ Recognising this situation raises ‘some very difficult and awkward questions’ to do with unplanned and unwanted pregnancy: ‘unplanned by whom? And more subtly, and more deeply, unwanted by whom?’

These difficult questions are central to the challenges facing policymakers today. We have moved a long way from the 1920s, when the first birth control clinics were set up to fulfil women’s desire for more scientific, reliable forms of contraception than coitus interruptus or abstinence. Women today have access to a range of contraceptive methods that enable us to assume that we can plan whether and when to have children.

But none of these methods are perfect. Some, such as the condom and the pill, are not hugely reliable at the best of times. The more reliable LARCs (long-acting reversible contraceptives), such as the IUD or the implant, can be uncomfortable to fit and remove, and these can also have unpleasant side-effects.

The current policy, Framework for Sexual Health Improvement in England, acknowledges that ‘LARC methods are not acceptable or suitable for all women, and it is important that women are allowed to make informed choices, with all the possible side effects and how these can be managed explained to them.’ The document also implicitly recognises that women need to be able to access abortion as a back-up to contraception:

‘For those women who request an abortion it is important that they have early access to services, as the earlier in pregnancy an abortion is performed the lower the risk of complications.’

However, the assumption behind this policy rests on the notion that pregnancies can and should be carefully planned, and that unwanted pregnancies can and should be avoided. This does not engage with what we know about the ambiguity around pregnancy intention and the ambivalence with which some women experience pregnancy: that the policy goal of eradicating unplanned pregnancy is not one that is actually shared by all women. 

What is really needed in the 21st century is a framework that explicitly moves beyond the rigid dichotomies of planned/unplanned, or wanted/unwanted, pregnancy, and allows for women to control their fertility in the way that is most appropriate for them at any particular time.

This means improving access to LARCs for women who are sure they have completed their families, or do not want to have children in the foreseeable future. But it also means recognising that other women will still prefer the condom, the pill, or ‘natural’ methods of contraception; that these methods will not always work; and that some of these accidental pregnancies will result in abortion while others are carried to term.

It means recognising that sex is not always planned for in advance, and supporting developments in pericoital contraception, which can be taken at the time of intercourse, and emergency contraception, which can be taken after the event.

Policy also needs to accept that planned, wanted pregnancies can become unwanted, and that women’s intention in becoming pregnant may still mean that she is ambivalent about being pregnant. The best framework would be one that supports the widest range of contraceptive choice and access to abortion, based on the recognition that only this combination will allow women to control their fertility in the way that they need to, whatever they may (or not) have planned.

The BPAS/Royal Society of Medicine conference, ‘Decriminalisation and demedicalisation: Rethinking family planning for the 21st century’, will take place in central London on 10 June 2015. See here for more information and to reserve your place. Early-bird ticket rates are offered until 12 May 2015; and places are limited, so early booking is advised.